Atrial Fibrillation What are the Options in 2016? David Spragg, MD, FHRS Johns Hopkins Hospital Cardiovascular Disease Management October, 2016
Disclosures Consulting, Biosense Webster
Overview What is AF? AF Burden Therapeutic considerations CVA risk and anticoagulation Rate versus rhythm control How to achieve rhythm control An illustrative case Conclusions and questions
What Is AF?
But I have noticed, that after the heart proper, and even the right auricle were ceasing to beat and appeared on the point of death, an obscure movement, undulation/palpitation had clearly continued in the right auricular blood itself for as long as the blood was perceptibly imbued with warmth and spirit. William Harvey, Exercitatio anatomica de motu cordis et sanguinis in animalibus, 1628
Haissaguerre M, et al. N Engl J Med 1998; 339: 659-66.
Calkins H, et al. HeartRhythm 2012; 9: 632-96.
AF Burden
Scope of the Problem Magnitude Over 3 million patients in the US with AF Projected 5.6 million in US with AF by 2050 Cost Correlation with stroke, heart failure, mortality Increasing toll on health care economics Increasing burden of risk Longevity, obesity, diabetes Go AS, et al. JAMA 2001; 285: 2370-75. Fuster V, et al. JACC 2011; 57: e101-98.
Increasing Burden Miyasaka Y, et al. Circulation 2006; 114: 119-25.
Mortality trends in patients with AF Miyasaka Y, et al. J Am Coll Cardiol 2007; 49: 986-92.
Therapeutic Considerations
Related but Distinct Discussions Reduction of CVA risk Rate- versus rhythmcontrol strategies CHA 2 DS 2 -VASC scoring Warfarin NOAC therapy LAA occlusion Symptoms Patient characteristics Age Duration of AF LA size; substrate Comorbidities Antiarrhythmics versus ablation
CHADS 2 and CHA 2 DS 2 -VASC Olesen JB, et al. BMJ 2011; 342: d124 (1-9).
Warfarin and NOACs Connolly SJ, et al. N Engl J Med 2009; 361: 1139-51. Patel MR, et al. N Engl J Med 2011; 365: 883-91. Granger CB, et al. N Engl J Med 2011; 365: 981-92. Connolly SJ, et al. N Engl J Med 2011; 364: 806-17.
Conundrum of Shared CVA and Bleeding Risks Hylek EM, et al. Circulation 2007; 115: 2689-96.
Proliferation of LAA Exclusion Devices Amplatzer Watchman Lariat Leal S, et al. Curr Cardio Rev 2012; 8: 37-42.
Bartus K, et al. J Am Coll Cardiol 2012.
Rate versus Rhythm control
AFFIRM AFFIRM Grp. N Engl J Med 2002; 347: 1825-33.
Saksena S, et al. J Am Coll Cardiol 2011.
Rhythm Control for AF Wann LS, et al. Circulation 2011; 123: 104-23.
Amiodarone versus Other AADs Roy D, et al. N Engl J Med 2000; 342: 913-20.
AAD Efficacy Calkins H, et al. Circ A& E 2009; 2: 349-61.
Rhythm control: Surgical Maze Dr. James Cox, Wash. Univ.
Evolution of Catheter Ablation Haissaguerre M, et al. N Engl J Med 1998; 339: 659-66.
Esophagus LAA Phrenic nerve RAO View PA View
Fire and ice Kuck KH, et al. NEJM 2016; 374: 2235-45.
Equally Effective Modalities Kuck KH, et al. NEJM 2016; 374: 2235-45.
What to Do with Persistent AF? Verma A, et al. NEJM 2015; 372: 1812-22.
Ablation Complications - JHH Yang E, et al. Europace 2016.
Catheter ABlation vs ANtiarrhythmic Drug Therapy in Atrial Fibrillation (CABANA) Trial Douglas L. Packer, MD Kerry L. Lee, PhD Daniel B. Mark, MD Richard A. Robb, PhD CABANA Investigators Mayo Clinic Rochester Duke Clinical Research Institute National Heart Lung and Blood Institute 3043464-38
A Case from Our Host 70yo woman AF CAD, EF 40% Chronic liver disease, s/p therapy for Hep C Never anticoagulated Symptomatic with dyspnea
Considerations CVA risk reduction CHADS VASC score of 4 (at least) Possible liver dysfunction, risk of GIB, coagulopathy Suggest trial of NOAC or warfarin LAA occlusion if GIB or other issues prevent anticoagulation, given moderate/high risk of CVA Rate v. rhythm control Dependent on: Symptoms LA size Type of AF (PAF v. persistent) Duration of continuous AF Contraindications to Amiodarone (if liver dysfunction an issue) Flecainide (ischemic CMP) Multaq (EF reduced, with CHF symptoms) Possible use of Sotalol or Tikosyn Consideration of ablation
Summary AF is a common and increasing problem Central questions include: CVA risk reduction Rate versus rhythm control Novel developments include New oral anticoagulants LAA occlusion devices Improved ablation modalities Ongoing challenges include: Improving ablation outcomes, particularly for persistent AF; early intervention Understanding different types of AF, and how to treat accordingly